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Prevalence and Risk Factors of Smoking and Vaping among Nursing Students in
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DOI: 10.56899/151.01.31

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Philippine Journal of Science
151 (1): 411-423, February 2022
ISSN 0031 - 7683
Date Received: 13 Sep 2021

Prevalence and Risk Factors of Smoking

and Vaping among Nursing Students
in a Private University in Manila, Philippines

Joseph Emmanuel P. Resano1, Maria Nicola d.A. Guce2, Zamantha Z. Manicio3,

Shanieal Marianne A. Serrano4, Sophia Paula A. Sicat5, Psalm Julianne M. Moreno5,
Aedre Gabrielle D. Semaña6, Ynnah Bianca S. Banzon5, Cassandra Louise C. Domingo-Gonzaga7,
Carolyn L. Nanca-Atayde7, Zypher Jude G. Regencia8,9, and Emmanuel S. Baja8,9*

1College of Nursing, University of The Philippines Manila

623 Pedro Gil St., City of Manila 1000 Philippines
2College of Science, De La Salle University Manila
2401 Taft Ave., Malate, City of Manila 1004 Philippines
3Department of Physical Therapy, College of Rehabilitation Sciences
University of Santo Tomas, Sampaloc, City of Manila 1008 Philippines
4College of Allied Health Professions
University of The East Ramon Magsaysay Memorial Medical Center
64 Aurora Blvd., Quezon City 1113 Metro Manila, Philippines
5Faculty of Pharmacy, University of Santo Tomas
Sampaloc, City of Manila 1008 Philippines
6College of Arts and Social Sciences, Mindanao State University–
Iligan Institute of Technology, Andres Bonifacio Ave.
Tibanga 9200 Iligan City, Philippines
7Senior High School, University of Santo Tomas
Sampaloc, City of Manila 1008 Philippines
8Department of Clinical Epidemiology, College of Medicine
University of the Philippines Manila, 547 Pedro Gil St.
City of Manila 1000 Philippines
9Institute of Clinical Epidemiology, National Institutes of Health
University of the Philippines Manila, 623 Pedro Gil St.
City of Manila 1000 Philippines

Nursing students trained to be health advocates have engaged in cigarette and electronic
cigarette (EC) use. Our study aimed to determine the prevalence of cigarette and EC use
among nursing students and examine how EC vaping and cigarette smoking are associated
with various risk factors. This cross-sectional survey of smoking and vaping was administered
to 249 nursing students in a private university in Manila, Philippines. An online-based self-
assessment questionnaire (SAQ) that includes socio-demographic information, cigarette and EC
usage, Perceived Stress Scale (PSS), and other risk factors was administered using on-campus
and online recruitment strategies. Generalized linear models were fitted to estimate the effect
of stress and other risk factors on smoking and vaping. Approximately one out of eight were
exclusive vapers, one out of 25 were exclusive smokers, and one out of five were both smokers

*Corresponding Author: esbaja@up.edu.ph

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Philippine Journal of Science Resano et. al, Electronic Cigarette, Stress
Vol. 151 No. 1, February 2022 and Nursing Students

and vapers. The prevalence of smoking/vaping was 47% higher [adjusted prevalence ratio
(aPR): 1.47, 95% confidence interval (95% CI): 1.04–2.07, p-value = 0.028] among students
with high-stress levels than students with low to moderate stress levels. In addition, students
who were sophomores (aPR: 1.69, 95% CI: 1.12–2.53, p-value = 0.012), juniors (aPR: 3.22, 95%
CI: 1.91–5.42, p-value < 0.001), and seniors (aPR: 1.53, 95% CI: 0.76–3.08, p-value = 0.230)
had a higher prevalence of smoking/vaping compared to freshmen students. Having a positive
attitude towards vaping health impacts and a smoker/vaper peer was also associated with
a higher prevalence of smoking/vaping. Therefore, effective health communication strategies
and policies in universities and the community are recommended to reinforce existing smoking
and vaping control efforts.

Keywords: E-cigarette, mental health, nursing student, perceived stress, Philippines, smoking and
vaping

INTRODUCTION Adolescents and young adults are mainly among the

More than 80% of the 1.3 billion tobacco users worldwide
live in low- and middle-income countries, including
the Philippines, wherein smoking-related preventable
illnesses remain the leading cause of death (PSA 2020;
WHO 2021a). Although there has been a significant
decline in tobacco use among adults in the country,
22.5% overall – or 15.1 million adults – still currently
smoke cigarettes (WHO 2019). In addition, the use of
rapidly emerging nicotine and tobacco products, such as
electronic or e-cigarettes or ECs, have been associated
with health risks – emphasizing the need for intensified
health research, education, and policymaking nationally
and globally (Al-Delaimy and Sim 2021; Immurana et al.
2021; Recto and Gayadan 2020).
Systematic reviews have highlighted the following:
existing evidence for the health hazards and toxicity of
nicotine, flavoring agents, and declared ingredients of
ECs; and the rising concern for the long-term adverse
effects of ECs and their increased use in general (Burstyn
2014; Cao et al. 2021; E. Fernández et al. 2015). These
findings mean that contrary to common assumptions, ECs
cannot be recommended yet as an effective, safe, and
healthy alternative tobacco product. Another problem is
that ECs can be a gateway product to substance use among
non-smokers. A recent meta-analysis of 30 longitudinal
studies revealed that the use of ECs increases not only
the risk of recurrence of smoking among current smokers
but also the risk of initiation of cigarette smoking among
never-smokers (Adermark et al. 2021). Therefore, as the
WHO emphasized in their report on addressing new and
emerging products on the global tobacco epidemic, EC
use is a public health concern and should be regulated,
considering its negative implications to smoking cessation
and addiction (WHO 2021b). Although there are vaping
regulation policies in the Philippines, current trends on the
users, market, and accessibility of EC suggest ineffective
control of such products (van der Eijk et al. 2021).
vulnerable population groups for cigarette and EC use
(Hammond et al. 2020; Wamamili et al. 2020). Curiosity,
enjoyment, and psychosocial factors related to family,
peers, and the school can explain to some extent the
smoking and vaping behavior of high school and university
students (Lindström and Rosvall 2018; Wamamili et al.
2020). Interestingly, even nursing students worldwide
have been found to have used cigarettes and EC, up to
40% prevalence for smoking and 12% for vaping, based
on recent multi-center studies and systematic reviews
(Fernández-García et al. 2020; Granville et al. 2017;
Martínez et al. 2019; Zeng et al. 2020).
In the Philippines, few studies have described smoking
among nursing students, and prevalence data and EC use
in this population are substantially understudied (Palmes
et al. 2021; Lubos et al. 2014; Zagada et al. 2015). This
is alarming as cigarette and EC use experience among
nursing students might harm their health as well as their
critical roles in health promotion and disease prevention.
It appears well-established that the smoking experience
of nurses can negatively impact their engagement and
credibility in implementing smoking cessation interventions
(Duaso et al. 2017; Rezk-Hanna et al. 2018; WHO 2014). A
literature review discussed that the smoking habits and lack
of expertise of health workers in Asia, particularly nurses,
prevent them from effectively delivering smoking cessation
education (Rahman and Huriah 2021). Another research
similarly found that among physicians in the Philippines,
their smoking status, lack of time, and inadequate training
are barriers in providing smoking cessation practices, which
may be the same for nurses as they tend to have more direct
patient interactions (Tan and Dy-Agra 2009). Smoking at
work or in front of patients as a standard practice is another
concern (Abdullah et al. 2014).
Studies suggested that the risk factors for nursing students’
use of cigarettes and possibly EC are not unique to their
population. For instance, they tend to smoke to relieve

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Philippine Journal of Science
Vol. 151 No. 1, February 2022
perceived stress, which compares to findings of cross-
sectional studies involving adolescent and young adult
students in general (Aho et al. 2019; Al-Rehaili et al.
2019; Lindström and Rosvall 2018). In addition, another
research explained that the stressful work environment
of healthcare professionals contributes to their smoking
behavior – that is, they use cigarettes to enhance their
mental function and mood and alleviate extreme physical
demands (Tan and Dy-Agra 2009).
Moreover, nursing students also practice smoking as a
way to socialize. Aho and colleagues (2019) analyzed
the discursive practices of nursing students in Finland,
revealing that the students rationalize their smoking
behavior because of life and academic stress and the
influence from their peers and family. Studies that also
investigated EC use among nursing students in Europe
and America had similar findings (Fernández-García et
al. 2020; van Devanter et al. 2016).
Nursing students are also found to lack knowledge
about the harmful health effects of cigarettes and EC use
and insufficient training in cessation interventions (D.
Fernández et al. 2015; van Devanter et al. 2016; WHO
2014). Their knowledge and attitude towards smoking and
vaping should be analyzed to inform nursing research and
education. It is essential as poor knowledge of smoking
health effects and approval attitude towards vaping appear
to be significantly associated with increased risk for
cigarette and EC use (Lotrean 2015; Sun et al. 2011a).
The role of nurses and other health professionals – as
counselors, educators, role models, advocates, and leaders
– is crucial in addressing the global tobacco epidemic
(WHO 2014). Unfortunately, current literature about
nursing students – particularly their use of cigarettes
and ECs and the surrounding risk factors – remain
concerning and limited. Existing knowledge is even more
so inadequate in developing countries like the Philippines.
This study aimed to determine the prevalence of cigarette
and EC use among nursing students in a private urban
university and examine if smoking and vaping are
associated with selected risk factors.
MATERIALS AND METHODS
Study Site and Population
This cross-sectional study was conducted on-campus and
online from March–April 2020 at the College of Nursing
of a private university in Manila, Philippines. The online-
based SAQ was initially available for on-campus and
online recruitments to facilitate maximum participation.
However, recruitment of the students switched to online
Resano et. al, Electronic Cigarette, Stress
and Nursing Students
when large-scale quarantine measures and lockdowns
against COVID-19 had started. Earlier on-campus data
gathering entailed students to answer the online-based
SAQ on campus. In contrast, the online SAQ was sent
and followed up via private messaging to school block
representatives. Both recruitment strategies required
the unique numerical subject identifiers assigned to the
participants who consent to participate in the survey.
Two hundred and sixty-three (263) out of the total 830
nursing students in the university were the target sample
size of the study. Inclusion criteria were legal age (≥ 18
yr old) and current enrollment status in the undergraduate
nursing program. Those who encoded themselves to be
of minor age were excluded. In addition, the students
provided informed consent, and the study received
institutional ethics review board approval.
Health Exposure and Outcome Assessments
Participants were asked to answer an online-based SAQ on
socio-demographic information, cigarette smoking and EC
usage, PSS, their knowledge on health effects of smoking
and attitude towards vaping health impacts, and the smoking
status and vaping status of their family and peers.
Perceived stress levels. The perceived stress level of the
students was assessed using the global instrument PSS
(Cohen et al. 1983). Permission was obtained to use the
Likert scale survey, which consists of 10 questions asking
how often one felt or thought a certain way in the past month
(e.g. feeling stressed, unable to control important things in
life, feeling overwhelmed). Responses were coded from
0–4 for “never,” “almost never,” “sometimes,” “often,”
and “very often” alternatives, respectively. Four of the 10
statements were positive and reversely scored (i.e. 0 = 4, 1
= 3, 2 = 2, 4 = 1). The total scores of the students from the
PSS were tallied and used to categorize the perceived stress
level of the students as low (PSS score: < 14), moderate
(PSS score: 14–26), or high (PSS score: > 27).
Knowledge of smoking health effects and attitude
towards EC use. The participant’s knowledge of the
health consequences of direct and secondhand smoking
was assessed using an adapted questionnaire (Fernandez
et al. 2010; E. Fernández et al. 2015; Schoren et al. 2017).
Nine and six health conditions (e.g. lung cancer, chronic
bronchitis, low birth weight, etc.) were asked regarding
their relationship with direct and secondhand smoking,
respectively. If the participant answered that cigarette use
is “a main cause,” “one of the main causes of the illness,”
“not related to the illness,” or “unknown relationship with
the illness” based on their knowledge, the participant was
given 2, 1, 0, and 0 point/s, respectively. The scores on the
knowledge of the participants were then categorized as
“not deficient” (> 8 for direct smoking; > 6 for secondhand
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Vol. 151 No. 1, February 2022
smoking) or “deficient” (< 9 for direct smoking; < 7 for
secondhand smoking) (Ordás et al. 2015). In addition, if a
participant thinks that smoking is mostly associated with
illnesses listed in the SAQ, then the participant will have
a “not deficient” knowledge and “deficient” otherwise.
Moreover, to assess the participant’s attitude towards
vaping, 17 questions were adapted (Schoren et al. 2017).
Perceived advantages were listed on a five-point Likert
scale, where 1 = “totally disagree,” 2 = “disagree,” 3 =
“neutral,” 4 = “agree,” and 5 = “totally agree.” Responses
were then dichotomized as “positive” (if the total score is
> 51) or “negative” (< 52). A “positive” vaping attitude
suggests that the participant is mostly neutral towards the
perceived benefits of EC use (e.g. as a healthy alternative
to smoking, socializing, relaxation, etc.). However, a
“negative” attitude then indicates contradiction to the
enumerated perceived advantages.
Cigarette smoking and EC use experience. Nursing
participants were classified into four groups: 1) never
smoker and vaper, 2) ever cigarette smoker only (current
or former smoker), 3) ever vaper only (current or former
vaper), and 4) ever cigarette smoker and vaper (current
or former smoker and current or former vaper). Questions
to measure such outcomes were adapted with permission
from ITC-PATH (International Tobacco Control Policy
Evaluation Project–Youth Tobacco and Vaping Survey
and Population Assessment of Tobacco and Health)
(Hammond et al. 2020; Li et al. 2020).
Branch logic, a survey feature in which the respondent’s
previous answers determine the following questions, was
utilized. To measure cigarette and EC use outcomes, a
multiple-choice question (“Which of the following have you
tried at least once in your lifetime?”) was first asked to classify
the respondents into the four groups. Those who answered
“both smoking and vaping” were categorized as ever smoker
and vaper (dual users). The ever-smokers and vapers were
directed to answer subsequent questions regarding which
substance they tried first and their reason for using cigarettes
and EC. Those who use cigarettes only were then asked about
their susceptibility to EC use in the future and the number
of cigarettes and times they have smoked in their lifetime.
These data provided information regarding current and former
exclusive smokers. These respondents were categorized as
ever smokers only (current or former smokers). In addition,
current cigarette smokers only were asked about their average
cigarette consumption, quit intention, and attempt. Lastly,
former smokers were asked regarding their quit method/s,
smoking urge, and susceptibility to smoking.
A “vaping/using ECs only” choice was categorized as ever
vaper only (current or former vaper). They were asked
regarding their susceptibility to smoking cigarettes in the
future and the number of times they have vaped. Moreover,
414
Resano et. al, Electronic Cigarette, Stress
and Nursing Students
current EC users were also asked regarding their average
duration of use, quit intention, and attempt. On the other hand,
vaping urge, susceptibility to vape, and quit methods were
gathered from former EC users. Lastly, non-smokers and
non-vapers were categorized as never smokers and vapers
and asked about their susceptibility to smoke and vape in the
future. Furthermore, the participant’s social influences were
also ascertained; whether their father, mother, other family
members, and friends/peers had ever smoked and vaped.
Statistical Analysis
Descriptive statistics for the prevalence of smoking and
vaping, the participants’ PSS scores, their knowledge and
attitude towards conventional cigarette and EC use, and
other covariates were calculated. The associations between
risk factors and the smoking and vaping status were analyzed
using a generalized linear model with a Poisson distribution,
a log link function, and a robust variance estimator, a more
suitable approach in analyzing cross-sectional data with
common outcomes (Barros and Hirakata 2003; McNutt
et al. 2003; Spiegelman and Hertzmark 2005; Tamhane et
al. 2016; Zou 2004). Additionally, the generalized linear
model was fitted to account for the heterogeneity in the
nursing student’s overall vaping and smoking. Moreover,
according to their smoking and vaping status, the nursing
students were classified into two outcome groups [never
smoker and vaper; ever smoker and/or vaper (ever smoker
only, ever vaper only, and ever smoker and vaper)]. Risk
factors were controlled a priori as potential predictors of
smoking and vaping in the model, including age, sex (male;
female), year level (freshman level to senior level), family
income (PHP < 50,000.00; PHP 50,000.00 and above),
family and peers smoking and vaping status (no cigarette
smoker and vaper; at least one cigarette smoker or vaper),
knowledge on direct and 2nd hand smoking health effects
(deficient; not deficient), attitude towards vaping health
impacts (positive; negative), and perceived stress levels
(low to moderate: PSS score < 27; high PSS score > 26)
(Bhat et al. 2011; Lee et al. 2018; Ma et al. 2018).
aPRs with 95% CI were reported as effect estimates for
the effect of age, sex, perceived stress level, year level,
and other risk factors on vaping and smoking. For all
analyses, a p-value of ≤ 0.05 was regarded as a threshold
for significance. STATA software version 17.0 was used
to carry out all the analyses.
RESULTS
Two hundred and forty-nine (249) nursing students
participated in the survey. The students had an average
age (± SD) of 19.4 ± 0.9 yr old, in which most of them
were females (77.9%). In addition, 90.4% were first- or
Philippine Journal of Science Resano et. al, Electronic Cigarette, Stress
Vol. 151 No. 1, February 2022 and Nursing Students

second-year students, and 73.4% had a family monthly Table 1. Characteristics of study participants (N = 249).
income of PHP 50,000.00 and above. Most of the
Characteristics n Value
participants were under moderate stress (77.5%) and
had a negative attitude towards the health impacts of Age, yr (mean ± SD) 249 19.4 ±
0.9
vaping (70.7%). Additionally, the majority of the students
(78.7%) had sufficient knowledge of the health effects of Sex (%)
direct smoking; however, more than half of them (56.2%) Male 55 22.1
had insufficient knowledge of secondhand smoking’s Female 194 77.9
health effects. For the smoking and vaping prevalence,
Year level (%)
approximately three out of five students were never
smokers and vapers, one out of eight were exclusive 1st 113 45.4
vapers, one out of 25 were exclusive smokers, and one 2nd 112 45.0
out of five were both smokers and vapers (see Table 1 for 3rd 6 2.4
the other study characteristics). 4th 18 7.2
Figure 1 shows the aPRs with 95% CI estimates for the Monthly household income, PHP (%)
effect of perceived stress level, knowledge on smoking < 50,000.00 66 26.5
health effects, attitude towards vaping health impacts, 50,000.00 and above 183 73.5
family and peers smoking and vaping status, and socio-
Attitude towards vaping health impacts
economic factors on the likelihood of students to smoke (%)
or vape. Students with high perceived stress levels had a
Negative 176 70.7
47% higher prevalence of cigarette smoking or EC vaping
(aPR: 1.47; 95% CI: 1.04–2.07; p-value = 0.028) than Positive 73 29.3
students with low to moderate perceived stress levels. Knowledge on direct smoking health
Moreover, the prevalence of smoking or vaping was 69% effects (%)
(aPR: 1.69; 95% CI: 1.12–2.53; p-value = 0.012), 222% Not deficient 196 78.7
(aPR: 3.22; 95% CI: 1.91–5.42; p-value < 0.001), and Deficient 53 21.3
53% (aPR: 1.53; 95% CI: 0.76–3.08; p-value = 0.230)
Knowledge on secondhand smoking
higher for students in the second-, third-, and fourth-year health effects (%)
levels, respectively, compared to students in their first-year
Not deficient 109 43.8
level. In addition, participants who had a positive attitude
towards vaping health effects tend to use the cigarettes or Deficient 140 56.2
EC 92% higher (aPR: 1.92; 95% CI: 1.42–2.60; p-value Cigarette smoking and vaping status of
< 0.001) than participants who had a negative attitude. family members (%)
Furthermore, students with at least one family member No cigarette smoker or vaper 41 16.5
(aPR: 1.34; 95% CI: 0.78–2.30; p-value = 0.284) or peer ≥ 1 cigarette smoker or vaper 208 83.5
(APR: 2.67; 95% CI: 0.65–11.04; p-value = 0.174) who Cigarette smoking and vaping status of
smokes or vape had a higher prevalence for smoking or peers (%)
vaping compared to students with family members or No cigarette smoker or vaper 17 6.8
peers who are never smokers and vapers (see Appendix
≥ 1 cigarette smoker or vaper 232 93.2
Table I for details).
Perceived stress exposure (%)
Low 16 6.4
Moderate 193 77.5
DISCUSSION High 40 16.1
Our study estimated the prevalence of never users of Outcome (%)
cigarettes and ECs to be 61%, which is very similar Non-smoker & vaper 152 61.0
to the 62–63% estimates found among nursing and
Cigarette smoker only 10 4.0
physiotherapy students in Spain (Ordás et al. 2015) and
university students in Korea (Jeon et al. 2016). Thus, our Vaper only 32 12.9
results may suggest that majority of nursing students have Both cigarette smoker and vaper 55 22.1
proper health behavior towards cigarette and EC use. On
the other hand, compared to the nursing studies in Europe,
our ever users of cigarette and/or EC prevalence estimate

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Philippine Journal of Science
Vol. 151 No. 1, February 2022
Figure 1. aPRs with 95% CI estimates for the effect of perceived stress level, knowledge on smoking health effects, attitude towards vaping
health impacts, family and peers smoking and vaping status, and socio-economic factors on the likelihood of students to smoke
or vape.
of 39% is almost twice higher than in Spain and Portugal
at 20% (Fernández-García et al. 2020) but lower than in
Italy at 60% (Canzan et al. 2019).
Our prevalence estimates highlight the importance of
smoking and vaping control and prevention measures for
the youth, whether school-based or community-based.
Existing public health interventions for smoking and
vaping should also be regularly evaluated, with vaping
control likely requiring an approach different from
regulating cigarette smoking. Implications might further
extend to how the future nurses would perform their health
promotion and clinical roles, such as patient counseling
and interventions related to substance use (Guevarra et
al. 2014; Ilic et al. 2020b). Education initiatives, such as
discussions and training concerning smoking and vaping
epidemiology and proper cessation techniques while
ensuring a non-judgmental approach, seem necessary for
students in the health professions programs (Franks et al.
2017; Roma 2020).
416
Resano et. al, Electronic Cigarette, Stress
and Nursing Students
In addition, in our study, most ever users were dual
users – having a higher prevalence than exclusive vapers
and exclusive smokers, which is similar to a study
among nursing students in Italy at 27, 3, and 23% rates,
respectively (Canzan et al. 2019). However, other studies
found more dual users than exclusive vapers but fewer
than exclusive smokers (Fernández-García et al. 2020;
Franks et al. 2017; Lotrean 2015). These findings bring
public health concerns as dual-use has been linked with
more negative respiratory and cardiovascular health
outcomes than the exclusive use of cigarettes or ECs
(Bozier et al. 2020). However, it should be considered
that these health impacts depend on the frequency and
intensity of smoking and vaping behavior, which our
study did not investigate among the dual users. Our results
should prompt further studies regarding the trial and
continued use of cigarettes and ECs among adolescents,
especially university students, including those in the health
professions programs. Curiosity about both cigarettes and
ECs as the top reported reason for dual-use is consistent
Philippine Journal of Science
Vol. 151 No. 1, February 2022
with research on university students and young adults
(Biener et al. 2015; Lotrean 2015; Sutfin et al. 2013).
Exposure to advertisements and peer use may account
for this finding (PSA 2020).
In contrast, some observations on adults and health
science students were different: health benefits, such
as smoking cessation and reduced harm and cigarette
consumption, primarily explain dual-use (Qanash et al.
2019; Schoren et al. 2017). Another study conducted in
a university in the United States found that young adults
tried ECs as an alternative to cigarettes (Hammond et al.
2020). This contrasting evidence proves that EC use is
not always used to aid in quitting and cutting back from
smoking cigarettes. Instead, it could lead users to increase
their exposure to nicotine substance addictive behavior
(Spindle et al. 2017). Further study to provide more
evidence whether ECs are more of a gateway substance,
a complementary substance to tobacco use, or an effective
smoking cessation tool may warrant our findings.
Lastly, exclusive smokers in our study (4%) appeared
to be the least prevalent compared to health professions
student smokers in other countries: 64% in the United
States and Saudi Arabia (Al-Rehaili et al. 2019; Franks
et al. 2017), 49.4% in Turkey (Öztürk et al. 2011), 47%
in Serbia (Ilic et al. 2020a), 27.1% in Ireland (Deasy
et al. 2014), 23.5% in Italy (Canzan et al. 2019), and
18.9% in Portugal and Spain (Fernández-García et al.
2020). Our estimate is close to the smoking prevalence
observed among public health and nursing students in
public universities in the Philippines and the United
States at 5.8 and 3.6%, respectively (Guevarra et al. 2014;
Roma 2020). Our findings may support the observed
decreasing trend of cigarette use (Ordás et al. 2015; PSA
2020), but the intensified implementation of anti-smoking
programs should further lower smoking in the community.
In addition, the previous smoking experience of ever-
smoker and their peers in this study could lead them to
subsequent use of cigarettes and the same level of curiosity
to the trial of EC (Biener et al. 2015; Goh et al. 2017).
Furthermore, looking at the prevalence of dual-use and
exclusive smoking in our research, smoking still seems
not uncommon even among nursing students. Theories
and clinical skills for smoking cessation interventions to
be instructed within the nursing curriculum and even in
continuing education programs may be helpful to counter
possible negative implications of the smoking history of
the students on their future healthcare roles (Aho et al.
2019; Guevarra et al. 2014; Ordás et al. 2015; Provenzano
et al. 2019).
Our study found a significant association between stress
levels and the use of cigarettes or ECs, which were in
agreement with several studies on nursing and other
health professions students (Al-Rehaili et al. 2019;
Resano et. al, Electronic Cigarette, Stress
and Nursing Students
Deasy et al. 2014; Öztürk et al. 2011; Qanash et al. 2019;
Yiğitalp 2015). In addition, among university students in
France, there was a positive relationship between regular
smoking and stress levels, which was also measured using
PSS (Tavolacci et al. 2013), and among male students
in Australia, between low to medium stress levels and
smoking (Sun et al. 2011a). However, no sufficient
evidence that stressful life events predict smoking and
vaping was found among college students in the United
States (Spindle et al. 2017). Another study suggested
stress as an insignificant correlate of cigarette use among
undergraduate nursing students in Hong Kong (Cheung
et al. 2016). Still, these findings may suggest that even
among nursing and health science students, perceived
stress can predict smoking and EC use behavior. Mental
health promotion early on, targeting adolescents and
young adults alike, may prove beneficial to further control
the tobacco epidemic.
In addition, our research found that participants in higher
year levels were more likely to smoke or vape, which
is consistent and in agreement with other studies that
describe smoking as a coping strategy among college
students (Naquin and Gilbert 1996; Sun et al. 2011b).
Moreover, the higher year levels in college induce more
stress among the students due to the increasing demands
in the university and the pressure to graduate (Ross et
al. 1999). Further studies examining the relationship
between stress levels and year level in college may merit
our initial findings.
Our study suggests that knowledge of the harmful health
effects of smoking was not a significant predictor of
cigarette or EC use. In other studies, however, nursing
students are more likely to be smokers if they consider
cigarette use as beneficial despite being aware of
associated harms, and so are the university students if
they lack the knowledge of the relationship between health
and smoking (Öztürk et al. 2011; Sun et al. 2011a). Most
students in our study did not have insufficient knowledge
of the harmful effects of direct smoking, but more than
half lacked the knowledge on secondhand smoking health
effects; however, neither appeared to have significantly
increased nor decreased the likelihood for smoking. More
studies among allied health students should investigate
their knowledge on the health effects of different risk
behaviors such as smoking and vaping and how it may
or may not affect their lifestyle.
Our study is in accord with previous studies that positively
perceived health impacts of vaping are associated with
smoking or vaping (Hammond et al. 2020; Lotrean 2015;
Ma et al. 2018; Schoren et al. 2017). More importantly,
the data corroborate findings on allied health students that
EC use is greatly influenced by the perception that vaping
is less harmful than smoking and is beneficial for tobacco
417
Philippine Journal of Science
Vol. 151 No. 1, February 2022
cessation (Franks et al. 2017; Qanash et al. 2019; Roma
2020). The unsupervised marketing efforts of EC products
and lack of credible health resources may have contributed
to the observed attitude of nursing students towards
vaping; this may be problematic for adolescents and
young adults as misinformation and lack of information
could increase substance use. Studies also mentioned
that available sources of information about vaping come
from advertisements and peer recommendations (Franks
et al. 2017; Hammond et al. 2020). The need for health
promotion programs and materials that can educate the
public regarding known risks and benefits of EC use in
different contexts must be highlighted, thus potentially
modifying and minimizing their health risk behaviors and
assisting them in making informed decisions (Bandura
1998; Jancey et al. 2018). Such initiatives could also
help them strengthen their foundation for future patient
counseling and community nursing.
Moreover, our research suggests the influence of friends
and family on either cigarette and EC use. Our results
on students whose friends were ever vapers agreed with
previous studies (Canzan et al. 2019; Hammond et al. 2020;
Vogel et al. 2018). We hypothesize that students who have
witnessed their friends use EC eventually become more
convinced to use one. In addition, the students of our study
whose friends have ever smoked cigarettes were likely to
smoke, which is consistent with the findings involving
nursing students in west Asian and European countries
(Canzan et al. 2019; Fernández-García et al. 2020; Yiğitalp
2015). These results further pose public health concerns as
using substances such as EC socially could lead to increased
and dependent use (Vogel et al. 2018). Intensified smoking
and vaping control measures for the youth and young adults
should therefore be considered.
Moreover, affirming previous nursing studies, the
likelihood of having ever used either cigarettes only
or both cigarettes and ECs among nursing students
significantly increased with having ever smoker friends
but not with ever smoker family members (Canzan et al.
2019; Öztürk et al. 2011; Yiğitalp 2015). The influence
of the family members of the students might be attributed
to the possibility that family members have been smoking
“irresponsibly” by not maintaining distance or not going
to a designated smoking area to minimize exposure of
others to secondhand smoke and images of an unhealthy
habit. Another reason could be that some students in
Metro Manila live away from their families, such as
in dormitories and condominiums, during school days
and have friends in their immediate social environment
instead. In this case, less parental guidance, new role
models, and negative peer influence could contribute to
more health risk behaviors of students (Nash et al. 2005).
Nonetheless, health promotion programs and materials
418
Resano et. al, Electronic Cigarette, Stress
and Nursing Students
may equip the students with more capability to have a
firm ground against peer pressure. In contrast, one study
found that among undergraduate health science students
in Malaysia, having parents with a smoking history was
a protective factor against vaping (Goh et al. 2017). Our
study further agreed with other studies that the smoking
behavior of family members influences cigarette use
among nursing students in Finland and Italy (Aho et al.
2019; Provenzano et al. 2019) and medical students in
Saudi Arabia (Al-Rehaili et al. 2019).
Interpretation of our study findings should be made
with consideration of certain limitations. Since the data
collected were self-reported, biases like nursing students
not fully disclosing truthful information or having the
social desirability to be accepted may have affected
our estimates in either direction. These biases were
minimized by promising anonymity and confidentiality
of their data and emphasizing their voluntary participation
in the survey. In addition, the sample size and limited
geographical scope of the study limit the generalizability
of the study to other nursing students in the Philippines or
elsewhere. Furthermore, most of the data were gathered
during the COVID-19 pandemic, which implemented
a strict nationwide community quarantine period.
Moreover, unmeasured confounding factor bias could
also not be ruled out in our study. Lastly, the study’s
cross-sectional design could not identify the temporal and
causal relationships between the various risk factors and
smoking/vaping outcomes.
CONCLUSION
Ever use of cigarettes, and ECs is prevalent among
undergraduate nursing students. Considering that most ever
users have tried both smoking and vaping and that ever
vaping has outnumbered smoking prevalence, further local
research studies on this emerging addictive behavior should
be a priority to inform relevant public health programs and
interventions. Furthermore, significant determinants of
smoking and vaping – stress levels, student’s year level,
having smoker or vaper friends and family members, and a
positive attitude towards vaping health impacts – highlight
the importance of active and intensified measures in the
community and schools to regulate smoking and vaping
among adolescents and young adults. These measures
may involve information campaigns, health education, and
counseling. Additional research in the nursing field also
seems advisable as their smoking and vaping experience
may have an impact on their preventive, promotive, and
curative healthcare duties.
Philippine Journal of Science
Vol. 151 No. 1, February 2022
ACKNOWLEDGMENTS
The authors acknowledge the University of Santo Tomas
(UST) Senior High School and its Health Allied Strand
for their support and assistance.
We also like to thank the respondents for taking the time
to answer our survey.
AUTHOR CONTRIBUTIONS
Study conception and design: JPR, MDG, ZZM, SMS,
SPS, PMM, ADS, YSB, CCD, CNA, ESB
Data collection: JPR, MDG, ZZM, SMS, SPS, PMM,
ADS, YSB, CCD
Data analysis and interpretation: ESB, ZGR, JPR, MDG,
ZZM, SMS, SPS, PMM, ADS, YSB
Supervision: CAN, CCD, ESB
Drafting of the article: all authors
Critical revision of the article: ESB, ZGR, and JPR
ETHICS DECLARATIONS
The study followed the Principles of the Declaration
of Helsinki (2013). It was conducted along with
the Guidelines of the International Conference on
Harmonization–Good Clinical Practice, National Ethical
Guidelines for Health and Health-related Research
(NEGHHRR) of 2017 and the Data Privacy Act of 2012.
This protocol has been approved by the UST College
of Nursing Ethics Review Committee (USTCON 2020-
SR01). Written informed consent to participate was
obtained from all of the participants.
STATEMENT ON CONFLICT OF
INTEREST
The authors declare that they have no competing interests.
The study was neither financially nor materially supported
by any institution.
FUNDING
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors.
Resano et. al, Electronic Cigarette, Stress
and Nursing Students
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APPENDIX

Table I. aPR with 95% CI for the effect of perceived stress, knowledge on smoking health effects, family and
peers smoking status, and socio-economic factors on smoking and vaping.
Characteristics Prevalence ratio for smoking/ p-value
vaping (95% CI)
Perceived stress exposure
Low to moderate 1.0
High 1.47 (1.04, 2.07) 0.028
Age 1.11 (0.90, 1.38) 0.336
Sex
Female 1.0
Male 1.12 (0.81, 1.54) 0.494
Year level
1st 1.0
2nd 1.69 (1.12, 2.53) 0.012
3rd 3.22 (1.91, 5.42) < 0.001
4th 1.53 (0.76, 3.08) 0.230
Monthly household income
< 50,000.00 1.0
50,000.00 and above 1.11 (0.77, 1.60) 0.565
Attitude towards vaping health impacts
Negative 1.0
Positive 1.92 (1.42, 2.60) < 0.001
Knowledge on direct smoking health effects
Not deficient 1.0
Deficient 1.15 (0.82, 1.62) 0.420
Knowledge on secondhand smoking health effects
Not deficient 1.0
Deficient 0.93 (0.69, 1.26) 0.643
Cigarette smoking and vaping status of family members
No cigarette smoker or vaper 1.0
≥ 1 cigarette smoker or vaper 1.34 (0.78, 2.30) 0.284
Cigarette smoking and vaping status of peers
No cigarette smoker or vaper 1.0
≥ 1 cigarette smoker or vaper 2.67 (0.65, 11.04) 0.174

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